We carried out this unannounced inspection on 10 January 2017.

Fewcott House provides nursing care for up to 40 people over the age of 65. At the time of our inspection 34 people were living at Fewcott House. Some people were living with conditions such as dementia or Huntingdon's Chorea or had a learning disability.

There was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service was being managed by a manager who had applied for registration with the Care Quality Commission.

We had previously carried out an unannounced comprehensive inspection of this service on 31 May 2016 and identified a number of areas where improvements were needed. We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. This was because there had been a failure to protect people from the risks of abuse and to report when people had been put at risk. Safe recruitment procedures were not followed when recruiting staff. People had not been protected by the safe management of medicines. Staff had not completed the necessary training to ensure they had the skills to undertake their roles and responsibilities effectively. Staff had not received regular one to one meetings with their managers to ensure they were supported and were being monitored to ensure they undertook their roles correctly. People did not always have appropriate assessments in place when they lacked capacity to make decisions. Policies were not always up to date and accurate with current best practice and terminology. Records had not been kept as required to monitor aspects of people’s health. The service was rated as inadequate in the well led domain.

We undertook this inspection to check the service had made the required improvements from the inspection on 31 May 2016. We found considerable improvements had been made in all areas of the service. The provider had ensured safe recruitment procedures were followed. The service had implemented a new care planning system and electronic system of managing medicines. This had improved the systems and processes to allow an effective overview of people’s care needs and their medication. Appropriate risk assessments were in place to manage any identified risks and people in the service and relatives we spoke with felt the service was safe.

Staff had completed the necessary training to ensure they had the skills to undertake their roles and responsibilities effectively. Staff had received regular one to one meetings with their managers to ensure they were supported and were being monitored to ensure they undertook their roles correctly.

People had appropriate assessments in place when they lacked capacity to make decisions.

People in the service and their relatives described the service as caring. We saw many examples of staff providing a warm and kind approach to those they supported on the day of the inspection. People were treated with dignity and respect and appropriate privacy. People were encouraged to maintain their independence skills.

Care plans had been implemented into an electronic system where staff were able to input the care given immediately and this meant the information was accurately recorded and where concerns were noted these were flagged up so that prompt action could be taken if needed.

Staff knew the people they were supporting well and activities were being arranged and future activities considered in line with people’s interests.

There had been no complaints since the last inspection but the service had systems in place to manage these. People and their relatives we

We visited Fewcott House Nursing Home on 31 May 2016. It was an unannounced inspection.

The service provides nursing care for up to 40 people over the age of 65. At the time of our inspection 33 people were living at Fewcott House. Some people were living with dementia or had a learning disability.

Prior to this inspection we had received concerns that people were not always being treated with dignity and respect and were not being protected against the risk of abuse.

We had previously carried out an unannounced comprehensive inspection of this service on 1 June 2015 and identified a number of areas where improvements were needed to ensure that people were receiving care that was safe, effective, caring, responsive and well-led. We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people had not always been treated with dignity and respect. Medicines had not been stored safely and staff had not received appropriate training or development. We also found that there were not effective systems in place to maintain records in relation to the management of the service to ensure safety and quality.

We undertook this inspection to follow up the concerns that had been raised prior to our inspection and to check the service had made the required improvements from the inspection on 1 June 2015. Not all of the improvements had been made.

This inspection was the seventh inspection of Fewcott House since February 2013. At each inspection we saw changes had been made to bring the service up to the required standard but also highlighted further areas for improvement. There has not been a stable management team at the home during this time, which meant the improvements had not all been sustained or embedded in practice. A new manager was in post because the registered manager had left in September 2015, however, they had not yet registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found there was a failure to protect people from the risks of abuse. The provider failed to recognise and report when people had been put at risk or had been subject to harmful situations. There had been unacceptable delays in the provision of information to the local authority safeguarding team and the Care Quality Commission.

The provider had not ensured safe recruitment procedures were followed when recruiting the new manager and other staff.

People had not been protected by the safe management of medicines. Procedures regarding ordering and stock control of medicines had not been followed by staff.

Appropriate risk assessments were in place to manage any identified risks. People in the service and relatives we spoke with felt the service was safe.

Staff had not completed the necessary training to ensure they had the skills to undertake their roles and responsibilities effectively. Lack of training had been identified at the last inspection but we found not all staff had completed this training at this inspection.

Staff had not received regular one to one meetings with their managers to ensure they were supported and were being monitored to ensure they undertook their roles correctly.

People did not always have appropriate assessments in place when they lacked capacity to make decisions.

People in the service and their relatives described the service as caring. We saw many examples of staff providing a warm and kind approach to those they supported on the day of the inspection. People were treated with dignity and respect and appropriate privacy. People were encouraged to maintain their independence skills.

Care plans were in place b

We visited Fewcott House Nursing home on 1 June 2015 It was an unannounced inspection. We previously inspected the service on 7 June 2014. The service was meeting the requirements of the regulations at that time.

The service provides nursing care for up to 40 people over the age of 65. At the time of our inspection 33 people were living there. Some people were living with dementia or had a learning disability.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and their relatives were complimentary about the registered manager and provider. The registered manager demonstrated a personalised approach and a commitment to providing good quality care. Since being in post they had made many changes and improvements for people living at the service. However, they required support and development to make further changes to bring the service up to the required standard. Systems were not always effective in monitoring the quality of the service and ensuring people were protected from harm. Some documents relating to the management of the service needed reviewing and updating. People felt able to raise any concerns with the management team and were confident they would be addressed promptly.

Medicines were not always stored in a safe way. Action was not taken to ensure medicines were always stored at the correct temperature and one medicine that could present a risk to people if not taken in the right way was stored within reach of people. People received their medicines as prescribed.

People felt safe and their relatives told us they did not have concerns about people’s safety. People were protected from abuse. There were enough care staff to meet people’s needs although a shortage of housekeeping staff meant communal lounge areas were not as clean as people would like them to be.

People told us they liked living at the home and were complimentary about staff. People felt they were treated in a caring, patient and friendly way. Whilst we observed many positive and caring interactions we also observed some interactions that meant people were not always supported in a way that was respectful. Staff did not always engage with people unless they were providing a care task. A lack of activity meant some people were bored and lacked stimulation. We have made a recommendation about the provision of activities at the service.

People were offered choice and their preferences were respected. People liked the food and were supported to maintain a healthy diet. People were referred for specialist advice as required.

Staff felt supported. However, gaps in training for both new and existing staff meant they were not always supported to improve the quality of care they delivered through training.

Although risks to people’s health were identified and plans were in place to minimise the risks, there was no systems to identify whether pressure relieving mattresses were set correctly. We identified one person with a mattress that was set too high for their weight which may mean they were not protected from developing a pressure ulcer. One person had behaviour that could be described as challenging. Although staff knew the person and understood their needs this information was not recorded in their care record.

The provider, registered manager and staff understood their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions or who may be deprived of their liberty for their own safety.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we took and what action we told the provider to take at the back of the full version of the report.

Fewcott House is a residential and nursing home providing nursing care and accommodation for up to 40 people. At the time of our inspection there were 29 people living at the home. The home cares for older people, some of whom are living with dementia or may have learning disabilities.

The home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider. Prior to the inspection the manager had not been working in a supernumerary capacity, and worked mainly as a nurse. The management had taken appropriate action following concerns raised at previous inspections regarding monitoring the quality of the home.

People told us they felt safe at the service and they were protected from abuse. Staff had knowledge of safeguarding and knew what to do if concerns were raised. We found the service was meeting the requirements of the Deprivation of Liberty Safeguards.

People felt that they were protected from risks associated with their care because staff followed appropriate procedures to protect them. People’s medicines were administered safely and the service had appropriate systems in place to ensure that medicines were stored securely.

People told us they were involved in decisions about the care and support they received and people were encouraged to express their views about their care. People received support and treatment that enabled them to stay as independent as possible.

People’s care plans reflected their needs, choices and preferences and people benefitted from effective care and treatment as staff had the skills and knowledge to meet people’s assessed needs and choices.

People were assessed to identify any risks associated with food and drinks and were involved in discussions about their nutritional needs. People also saw dietary and nutritional specialists when needed.

The service was caring because staff treated people with kindness and compassion and respected their dignity. Staff used people’s preferred names throughout our visit and people were comfortable with this. People’s preferred names and titles were recorded in their care assessments. However staff did not always take the time to talk with people. We observed that staff often moved around the home but did not always acknowledge people and we saw people were often withdrawn or sleeping and one person became agitated when staff members did not acknowledge them.

Not all of the people who used the service had access to activities that appealed to them. However, people who spent time in their own rooms were protected from the risk of social isolation as staff and people told us they spent time talking to them.

People and their representatives were encouraged to make their views known about their care, treatment and support. People had their needs assessed and support was sought where necessary. The manager and provider planned to develop good practice of care within the home. Staff told us they contributed to improving the practice of staff. Staff felt motivated, well supported and trained.

We carried out this inspection to see if the provider had made improvements since our last inspection in August 2013. At that time we had concerns about the standard of care and welfare experienced by people who used the service, how staff were trained and supported and how the provider monitored the quality of the service.

During this inspection we saw the provider had implemented processes that had led to improvements in the service. We found that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Staff we spoke with told us they felt supported and had received training and supervision. One told us “I feel supported, it’s good since [the manager] came. Everything is more organised”. One person told us “it’s my home and I’m happy here”.

During our inspection we looked at the provider’s quality assurance and risk management systems. At our last inspection we identified that the provider did not have an effective system to regularly assess and monitor the quality of the service that people received. We also found that the provider did not have an effective system to identify, assess and manage risks relating to the health, safety and welfare of people who used the service. At this inspection we found that the provider had introduced some systems to evaluate the quality of the service and to identify, assess and manage risks. However, we found that some of these systems were not being effectively operated. We also found that the provider did not have comprehensive oversight of the risks affecting all aspects of the service and therefore the approach to managing risks was not coordinated and structured.

Records relevant to the management of the service were not always accurate and fit for purpose. For example, records relating to the supervision of staff. Records were not always kept securely and could not always be located promptly or easily.

We conducted a visit in response to concerns we had received regarding Fewcott House. During our visit we spoke with eight people who used the service, 12 members of staff and two relatives. We looked at 11 people’s care plans and staff training and supervision records.

We found that people’s needs had been assessed, but that care and treatment had not always been planned and delivered on the basis of the assessments. For example, where people had been assessed as having a very high risk of developing pressure areas it was not always clear what actions staff should take and were taking to reduce and manage the risk.

We found that there were enough suitably qualified and experienced staff on duty to meet the needs of the people. However, we found that staff were not always appropriately supported to carry out their role. For example, nursing staff had not received regular supervision and appraisal.

The provider did not have suitable systems in place to assess and monitor the quality of the service that people received. People were sometimes exposed to care that was not always safe due to a lack of quality monitoring.

We found that notifications to CQC of deaths of people who used the service had not always been made.

During this inspection we spoke with five people who used the service two relatives and five members of staff.

We found that care plans and assessments contained detailed information about people’s preferences and choices. One person told us "I can choose when I go to bed and when I want to get up, I choose what to wear".

We found that people were treated with care and respect and received care in a way they preferred. One relative told us “the staff here are wonderful, they cannot do enough for you”. A person using the service told us “the staff are very caring”.

Staff were supported and trained to enable them to deliver good care One care worker told us " I have supervision every two months, I find it really helpful with my role.”

We found the service had quality assurance methods in place, which involved people, to make sure they maintained and enhanced the quality of the service they were providing.

People we spoke to were happy with the service they received and knew how to complain if they had a concern. One person we spoke with told us “I could complain if I needed to but there is nothing to complain about here".

During the inspection we spoke with eight people using the service; two relatives; and seven members of staff.

People’s healthcare needs had been assessed and regularly reviewed. People using the service had access to other professionals to ensure that their healthcare needs could be met.

Whilst the majority of staff were observed to have kind and respectful manner, there was one occasion when a person’s needs were not met in a person-centred way. The manager subsequently confirmed that action had been taken to prevent any reoccurrence.

Safeguarding was taken very seriously and staff were aware of their responsibilities. Management took appropriate action to ensure the wellbeing of people using the service.

Improvements had been made to the environment and the programme of refurbishment was continuing. One relative commented that ‘standards are improving constantly’.

Dependency measures were used to identify the number of staff needed on duty. Additional staff were being recruited. Staff groups had clearly defined duties to ensure that care was not compromised.

The manager and CEO monitored the care and service being provided. A relative said that their opinions were sought and valued. Plans to provide appropriate formats to obtain the views of people using the service would make the formal quality assurance process more inclusive.

People who lived in the home told us that it was a ‘magnificent home', they felt safe and happy. They were happy to talk to staff if they had any concerns and were confident that they would be dealt with. We were told that people were treated with ‘great respect’.